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Sir,

Acute dacryocystitis involves suppurative inflammation of the lacrimal sac and perilacrimal tissue, usually secondary to blockage of the nasolacrimal duct with resultant stasis. It commonly resolves on systemic antibiotic therapy, with or without surgical drainage.1 We present a case of ‘dacryocystitis’ unresponsive to conventional antibiotic therapy, which on subsequent investigation proved to represent squamous cell carcinoma arising from the paranasal sinuses.

Case report

A 79-year-old female subject presented with a 5-week history of right epiphora and bilateral medial canthal pain. In response to oral amoxycillin, prescribed by her physician, the watering and pain at the right medial canthus had resolved; pain, redness, and swelling, however, persisted at the left medial canthus. Her medical history included type II diabetes mellitus, systemic hypertension, and osteoarthritis.

On examination, the left medial canthal area was swollen, erythematous and tender, manifesting a ‘pointing’ fluctuant mass suggestive of a lacrimal abscess. A conjunctival swab was taken for bacterial culture and sensitivity testing. Systemic coamoxyclav and flucloxacillin were prescribed on an outpatient basis.

After 10 days, there was symptomatic improvement and the mass was smaller. The nasal bridge, however, appeared flattened; on palpation, the mass was now hard, nontender, and immobile. Bacterial cultures had been nonproductive. Otorhinological opinion was therefore urgently sought. CT scan revealed an irregular soft-tissue tumour of the paranasal sinuses, centred on the nasal bridge, extending laterally to involve both medial canthi, posteriorly to involve the sphenoethmoid recess, and superiorly to involve the anterior cranial fossa (Figure 1). Fine-needle aspiration cytology confirmed a diagnosis of squamous cell carcinoma. In the absence of systemic metastatic disease, radiotherapy was adjudged the most appropriate therapeutic option.

Figure 1
figure 1

CT scan shows a midline soft-tissue mass eroding the nasofrontal complex, which extends laterally to involve the medial canthus of the left orbit.

Full size image

Comment

Acute dacryocystitis is not uncommon in the elderly. Inflammation of the paranasal sinuses has been reported to masquerade as ‘pseudodacryocystitis’.2 Recurrent or resistant ‘dacryocystitis’ should however, alert the clinician to the possibility of other serious underlying pathology. It is also noteworthy that the clinical features of a mass may be initially deceptive, especially if coloured by superadded infection or inflammation — hence the need for serial critical evaluation.

Tumours of the paranasal sinuses and nasal cavity account for 0.2–0.8% of all carcinomas in the body.3 In the UK, the incidence of nasal tumours is about 10 per million population per year.3 As with any rare condition, a high index of suspicion is therefore essential. Owing to the anatomical proximity of the nasal cavity and sinus to the orbit, pharynx, roof of oral cavity, and cranial structures, tumour spread may produce variable clinical presentations including proptosis, Horner's syndrome, ophthalmoplegia, epistaxis, loose-fitting dentures, and ninth and tenth cranial nerve palsies.

Therapeutic options for disseminated disease include radical surgery, radiotherapy, and chemotherapy or combination therapy. Half of such tumours are incurable.3, 4 Nevertheless, a conservative approach almost invariably results in further disfigurement, rendering the aforementioned modalities valuable in this context.

Serial clinical evaluation of any unusual mass, coupled with a high index of suspicion is, therefore, vital until definitive diagnosis is established. Prompt referral to other specialties is also of paramount importance in the context of any diagnostic uncertainty.